Discussion of public health and health care policy, from a public health perspective. The U.S. spends more on medical services than any other country, but we get less for it. Major reasons include lack of universal access, unequal treatment, and underinvestment in public health and social welfare. We will critically examine the economics, politics and sociology of health and illness in the U.S. and the world.

Wednesday, May 17, 2006

Driving us nuts

Mental illness, mental health, the realm of psychiatry and psychology -- whatever you want to call it -- presents some of the problems in the sociology and philosophy of health and illness in particularly high relief. I'm going to touch on some of the highlights now, which is all I can do in a single blog post. I've written about some of these specific issues in more depth before, for example here where I discuss the apparent "epidemic" of mental illness and explain it as a growing availability of diagnostic labels; here, where I discuss the problem of evil in the context of biological theories of the mind; and here where I discussed the very different kinds of criteria that can lead to a diagnosis of mental illness -- personal distress, disability, or the disapproval of others.

But now I'm just going to take a quick look around from the treetops. Psychiatry has always been in an uncomfortable relationship with the rest of medicine. Whenever the specific, biological basis of a formerly psychiatric disorder is fully understood, the disorder tends to leave the realm of psychiatry and become the province of neurologists, or possibly some other kind of doctor such as an infectious disease specialist. I mentioned recently that tertiary syphillis used to be conflated with schizophrenia. Now that we know it is an infectious disease, it is no longer considered a psychiatric disorder. Similarly, the dementias associated with aging used to be considered "insanity," but today people with Alzheimer's Disease and vascular dementia see neurologists, not psychiatrists. (The neurologists can't do anything for them either, but we still pay for visits.)

Psychiatric diagnoses depend, not on X-rays or blood tests, or feeling lumps or hearing odd sounds from the viscera, but on checklists of behaviors. If you have two from column A and three from column B, you have the disease. There are several problems here, of which the most basic are:

Somebody has to decide that the behaviors in question are undesirable or pathological;

Somebody has to decide that a certain amount of them, in a certain combination, constitutes a "disease";

Somebody has to decide that Hermione Hassenfeffer does, in fact, manifest the necessary combination of behaviors in sufficent degree to merit the diagnosis.

I try to be pragmatic, rather than profoundly philosophical about this. Sometimes the reality of psychiatric disease is not worth disputing -- it can be like Justice Potter Stewart's definition of pornography: "I know it when I see it." People who are walking down the street having loud, incomprehensible conversations with entities who are not there are either schizophrenic, or they are cell phone users.

However, even in this case I must acknowledge recent commenter Spiritual Recovery, who experienced a psychotic break and then recovered without the usual drug treatment. This can certainly happen -- it happened to Kurt Vonnegut Jr.'s son Mark, who wrote a book about it. One question is whether jumping in immediately with antipsychotic drugs can actually exacerbate the situation. Would more people recover spontaneously if we didn't start messing with their brains? Maybe, who knows? There is also the question of whether there are cultural contexts in which people who we would consider mentally ill may have a useful social role to play as shamans or visionaries, which enables them to channel and manage their hallucinations. I have heard of this idea before, I don't have any personal knowledge as to its validity. Certainly it doesn't apply to everybody who we would label as schizophrenic -- people who are severely disabled by schizophrenia-like symptoms who up just about everywhere, as far as I know.

But the general point is a strong one. The existence of schizophrenia certainly does depend on the social context, at least at the margins. Ted Kaczynski was diagnosed with paranoid schizophrenia (thereby sparing him execution) although he does not have hallucinations or hear voices. His conviction that industrial civilization is bad for humanity was ruled delusional by the court appointed psychiatrist. Hmm. Exactly what constitutes a delusional belief system is, inevitably, in the eye of the beholder.

But other diagnoses are far less certain and stable than the diagnosis of schizophrenia. I've said a lot about depression. Everybody knows that the difference between the normal human experiences of sadness and grief, and the disease of depression, is a matter of judgment. There are extreme cases where almost everyone would agree that there is something intractably and disturbingly wrong with a person; and there are probably many more cases that people would argue about.

But at least depressed people generally speaking don't like being depressed and want relief. There is another category of diagnoses in which the allegedly sick person feels just fine, thank you. Homosexuality used to be one of them. To the extent homosexuals felt they were diseased, it is because that is how other people treated them. They felt guilty, rejected, humiliated -- but they liked having sex with people of the same sex. Now the APA has been persuaded not to call homosexuality a disease, and even if it's no picnic being gay in Kansas, you can move to the South End or Greenwich Village and everything will be just fine.

The personality disorders which remain on the list also tend to be questionable, although in different ways and perhaps to a lesser extent. Sociopaths have something wrong with them because the rest of us say so. Generally speaking, they do not agree. What kind of a "disease" is it that the victim doesn't mind having? People with so-called borderline personality disorder drive the rest of us nuts, but they think it's our fault. They are usually quite unhappy, but they attribute to the people around them, not to themselves. Well, we aren't about to change to make them happy, even if it were possible. But these "diseases" are matters of degree, they manifest in enough different ways that it isn't clear that they are always the same "thing," if they are a thing at all, and it isn't clear that they ought even to be called diseases.

It is common to justify the concept of mental illness in terms of functional impairment and disability. If people can't hold a job, can't have stable and satisfying relationships with others, can't maintain their personal hygeine, and so on, something is clearly wrong. But again, that may be a consensus, but it's a matter of context, and opinion. Not everyone holds a job, after all, and we don't consider non-working spouses to have anything wrong with them. Quite possibly many of them would not be able to hold a job, were they put to the test. What about the people we used to call hobos, migrants who may take odd jobs but are content to be homeless and camp out in out of the way places? There are many people with odd behaviors, who might merit a diagnostic label, who live on the margins of society but seem reasonably content.

Psychiatrists want to be credible within the medical profession. In the past, there was little or no demand that psychiatric treatments be proven efficacious by the methods used for medical treatments. For that matter, medical treatments didn't have to be shown to be effective either, but psychiatry came to the evidence-based game comparatively late. The theories used by psychiatrists were firmly held and passionately defended, but they were largely speculative and often quite fungible and vague. Psychiatrists used to be convinced that schizophrenia was caused by suppressed conflicts and desires, and that autism was caused by emotionally distant mothers. Now they give drugs for schizophrenia and autism has been handed to the neurologists.

Oh yes, drugs. Although psychiatric disorders, almost by definition, are of unknown etiology, in order to be considered "scientific" psychiatry needs randomized controlled trials. It's a lot easier to do one for a drug than it is for talk therapy. For one thing, drugs are perfectly standardized -- a specific dose of a specific chemical. Counseling is very difficult to package as a standard product in a standard dose. For another, although psychiatrists nowadays like to talk about "rewiring neural circuits" by talking to people, they don't really have any way of proving that they have done so. Even if nobody knows how the drugs work, at least everybody believes that they are doing something concrete and biological.

Having said all of this, let me be absolutely clear. However problematic the concept of mental illness, there really are people with mental illnesses, who really do suffer, and who are best served if we agree that they are sick. There should be no more stigma associated with mental illness than there is with influenza, heart disease or diverticulosis. There should be equal access to appropriate, comprehensive treatment. There should be an equal commitment to making sure that treatments really work. But we need to understand mental illness correctly, and that requires a very critical, skeptical examination of the current set of concepts, the system of care, and treatments.

That's something I will try to do more of here. I'm very interested in hearing people's ideas about all this.